CQC report explained · a residential care home
What the CQC found at Underhill House Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe. Inspectors found enough staff, safe recruitment, suitable risk checks and safe medicine systems.
- Effective?
- Good
- People received suitable food and drinks, staff were trained and supported, and people could access health services when needed. The home was asked to review its signage.
- Caring?
- Good
- Inspectors found kind and considerate care. People were treated with dignity, offered choices and supported to remain independent.
- Responsive?
- Good
- Care plans included people's histories, needs and preferences, and activities and visits were available. Some care plans needed more specific instructions, and some end of life planning needed follow-up.
- Well-led?
- Good
- The home had a clear management structure, regular checks and an open culture. Staff said they felt supported, and the management team acted on identified improvements.
What inspectors found, February 2020
Underhill House Residential Home is rated Good; inspectors found safe, kind and personalised care, with some care records needing more detail.
This was an unannounced inspection on 23 January 2020. Inspectors spoke with people living in the home, relatives, staff and visiting professionals. They observed care and checked care, medicine, staff and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicine arrangements, clean surroundings, kind staff and good access to health services.
People had choices about daily life, food, activities and visitors. Inspectors recommended reviewing signs around the home because its layout could be confusing. They also asked for more detail in some care records and further work on some end of life care plans.
Enough staff
Inspectors found staffing levels were sufficient and could be adjusted when people's needs changed.
“There were enough staff to meet the needs of people.” from the report
Kind, respectful care
People and relatives described a family atmosphere. Inspectors saw staff treating people with kindness, dignity and respect.
“People were treated with dignity and respect and their families welcomed whenever they visited.” from the report
Food and hydration
People were positive about the food. The home catered for specialist diets and made drinks available throughout the day.
“People were offered a range of drinks with their food and throughout the day to stay hydrated, and these were in reach.” from the report
Regular management checks
The home checked areas such as infection control, safety, care planning, equipment and staffing, and acted on issues found.
“Audits were completed regularly with key areas such as infection control, health and safety, care planning, equipment checks, and staffing records checked.” from the report
Signage could be clearer
minorThe older building had a mildly confusing layout. Inspectors recommended reviewing the signs to make it easier for people to find their way around.
“Some further signage may have made the service easier to navigate.” from the report
Some care plans lacked detail
needs fixingSome records did not give enough specific guidance about how staff should provide personal care, including people's preferred toiletries and approach.
“We fed back that although some areas were detailed there could be further specific instruction in how staff were to deliver support.” from the report
End of life plans needed follow-up
needs fixingThe home had made a sensitive start on recording end of life wishes, but some plans still needed to be discussed and completed with people and relatives.
“However, it required following up with some people and relatives.” from the report
- 01What changes have you made to the signage since the inspection to help people navigate the building?
- 02How do you make sure care plans give staff clear, personalised instructions about personal care and preferred toiletries?
- 03How do you record and review each person's end of life wishes with them and their relatives?
- 04How are diabetes-related risks assessed and kept up to date?
- 05How have the service and its staffing arrangements changed since the January 2020 inspection?
This was an unannounced planned inspection covering all five CQC questions, including the care provided and the premises; all five ratings remained Good from the previous inspection. This explanation was written from the published report of 14 February 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2017
Rated Good in all five areas; inspectors found kind, personalised care, with some medicines, dementia support and cleanliness issues to address.
Inspectors made an unannounced, comprehensive visit on 26 June 2017. They spoke with people living at the home, relatives and staff. They also reviewed care records, medicines, training, accidents, fire safety, audits and other documents.
The home was rated Good overall, and Good for Safe, Effective, Caring, Responsive and Well-led. People told inspectors they felt safe, received kind care and had enough to eat and drink. Staff knew people well, respected their dignity and supported personalised care and activities.
The inspection found that improvements requested after the March 2016 inspection had been made. These included better risk management, medicines systems, consent checks, complaints handling and quality monitoring. However, some topical medicines were not dated when opened, staff did not always check that medicines had been taken, and the environment was not fully dementia-friendly.
Kind and respectful care
Staff were calm and patient. They knew people well, used preferred names and protected privacy and dignity.
“Staff demonstrated a calm and patient approach and spoke fondly of the people they cared for.” from the report
Safe staffing and recruitment
Inspectors found suitable staffing levels and checks to make sure new staff were suitable to work with vulnerable people.
“People were supported by suitable numbers of staff to meet their individual needs.” from the report
Personalised support
Care plans were redesigned to give staff accurate information about individual needs. People could choose activities, personalise bedrooms and maintain religious links.
“People received personalised care, and had care plans in place which were reflective of their individual needs.” from the report
Improvements since the last inspection
The home had acted on earlier concerns about risks, medicines, consent, complaints and quality monitoring.
“During this inspection we looked to see if improvements had been made and we found that action had been taken.” from the report
Visible leadership
The provider was available during the inspection, and staff said they could contact the provider when needed.
“The provider was available and visible throughout the inspection.” from the report
Medicine checks
needs fixingSome creams and gels were not dated when opened, creating a risk they could be used after their expiry date. Staff did not always check that people had taken medicines before signing the records.
“However, people's topical medicines (creams or gels) were not always dated upon opening, which meant there was a risk that they may be used past their expiry date.” from the report
Checking medicines were taken
needs fixingAt lunchtime, staff were not always vigilant that people had taken medicines from their medicine pots before records were signed.
“Staff at lunch time, were not always vigilant in ensuring when people had been given their medicines in their medicine pot, that they had taken them.” from the report
Dementia-friendly signs
minorThere was a picture sign for the dining room, but not for all other areas. Inspectors said this could make it harder for people living with dementia to find their way around.
“This meant people living with dementia may find it difficult to orientate to their environment.” from the report
Bathroom odours
minorSome bathrooms smelled unpleasant because clinical waste bags had not been emptied when full. The provider said the emptying arrangements would be reviewed.
“In some bathrooms, there was an unpleasant odour, this was because clinical waste bags had not been emptied when full.” from the report
Sharing survey results
minorSatisfaction questionnaires had positive results, but the information had not been brought together and shared with people.
“The overall results of the questionnaires had been positive, however the information had not been collated and shared with people.” from the report
- 01How do you now make sure creams and gels are dated when they are opened and not used past their expiry date?
- 02How do staff check that people have taken medicines before signing the medicine records?
- 03What changes have been made to signs and other features to help people living with dementia find their way around?
- 04How often are clinical waste bins emptied in bathrooms, and how is this checked?
- 05How are satisfaction survey results now collated and shared with people and relatives?
This was an unannounced comprehensive inspection covering all five questions, so all five ratings were assessed during the visit. This explanation was written from the published report of 1 August 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Underhill House Residential Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- February 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Underhill House Residential Home →
- August 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Underhill House Residential Home →
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 22 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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